…by Ed / from Cumbria, England / studied Medicine / 6th Year (UG)

The medical ‘elective’ is an incredible opportunity all medical students have to experience healthcare in a different part of the UK or on a different continent. We can choose to spend six weeks as a student at a hospital anywhere in the world. I am in the The Gambia for my placement. It is the smallest country in mainland Africa, wedged between north and south Senegal. I spent some time at a large research hospital on the coast called the Medical Research Council Unit in addition to a small rural mission hospital inland. It was fascinating to discover similarities and differences between these two settings and with my experience of UK healthcare.

Shortly before I arrived in The Gambia, in December 2016 there was a hugely disruptive political crisis in the country¹. After initially conceding defeat, Yamya Jammeh, the sitting dictator president of 22 years was refusing to leave office despite losing an election. Troops and warships from Senegal and other countries in West Africa surrounded the border and started moving in to remove him by force. After a six-week period in which 46,000 citizens fled the country, he eventually stepped down peacefully and left for Equatorial Guinea. This crisis almost disrupted my plans to come to The Gambia, but I’m hugely thankful that in the end I able to come and enjoy this beautiful country and meet its welcoming people; The Gambia is called ‘The Smiling Coast’ for a good reason!

Relaxing in a hammock.

My experience here has certainly been very different to the hospital placements we have in NHS Scotland. As an example, one 31-year-old woman attended the day clinic complaining of “weakness” in her left leg. She was reluctant to give further information and so I continued to examine her nervous system by checking her muscle tone, power and the ability of the skin to feel and respond with a reflex to certain actions. It was only when examining her lower leg that I saw a large ulcer covered with some kind of brown/green substance. It transpired that this patient had actually developed the ulcer several weeks previously, and had visited the local traditional doctor – called the maribu – to get it looked at. The maribu had packed the ulcer with manure and grass to try and treat it – a treatment which hadn’t been effective at all, merely adding more bacteria to the ulcer. As patients can do in any doctor’s clinic, the woman was too embarrassed to mention this information initially because of the fear of disapproval from the healthcare staff. I felt pity rather than disapproval, however. The majority of patients in would go to the maribu before seeking help from medical professionals . They hold incredible power in local communities through the fear they exert on people. For example, the maribu attacked one friend by releasing several hundred bees onto him because he rebelled against them. He was lucky to be alive because they stung the inside of his throat, potentially suffocating him as the windpipe swelled up. Time and time again I saw the devastating effects that the negative influence of the maribu were having on the health of patients – at great financial, emotional and physical cost.

Going to the maribu first for medical care meant that when patients finally ended up at the Western hospital, their medical complaint was much further advanced, and often complicated by interference from the maribu. Another patient in his mid-twenties had a severe kidney condition, causing his whole body to swell up and blood and protein to leak into his urine. He had been treated by the maribu for six weeks before coming to hospital because he still felt so unwell – at which point his blood pressure was dangerously high. We had to arrange urgent treatment for him in another hospital. His kidney condition could have been recognised and treated at a much earlier stage if going to the maribu had not hampered his recovery so . This was particularly memorable due to this Gambian man being a similar age to me.

As well as seeing patients like these, I was given the opportunity to improve the effective recognition and management in The Gambia of an emergency condition called sepsis. Sepsis is a life-threatening state that arises when the body’s response to an infection injures its own tissues and organs. In the UK we have some brilliant guidelines which have halved the number of deaths from sepsis². It has been saddening to see several patients die from sepsis during my time here, and I was so grateful to have the opportunity to improve recognition and management of this condition to hopefully make some positive impact long after I leave The Gambia.

Sepsis screening protocol cards.

With support from a supervising consultant, I presented my full analysis and recommendations to the lead clinicians, proposing to design and implement a sepsis screening and action protocol for the hospital. Every new patient admission is now screened using that I designed based on the UK Sepsis Trust guidelines (see above). Any patient who breaches one of the criteria (e.g. level of alertness, breathing rate, oxygen saturation, heart rate and blood pressure) activates the sepsis protocol and will be seen by a ward nurse and doctor immediately. Published medical papers have long emphasised the urgency of dealing with septic patients,³ so it was deeply satisfying to train nurses in dedicated sessions to recognise and manage these patients quickly. My hope is that this initiative will further the delivery of excellent healthcare in The Gambia by saving lives in the long term.

Training nurses.

Although I’ve been busy, coming to The Gambia has been brilliant for taking time to relax after the business of sitting final exams recently in Edinburgh. Some highlights so far have been swimming in mangroves (I did check for crocodiles), a sombre boat trip to Kunta Kinte Island (formerly a slaving ship launch point), getting involved in a local church, joining the Gambia Ultimate Frisbee Club, catching up with old friends from the UK, beach time and even making a fleeting unofficial visit to Senegal when I swam across the river last weekend!

Ultimate frisbee team.

References

1. BBC. Gambia’s President Jammeh refuses to leave office as deadline passes. Available from: http://www.bbc.co.uk/news/world-africa-38672840
2. Daniels R, Nutbeam T, McNamara G, et al. The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study. Emerg Med J 2011;28(6):507-12. doi: 10.1136/emj.2010.095067 [published Online First: 2010/10/29]
3. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006;34(6):1589-96. doi: 10.1097/01.CCM.0000217961.75225.E9

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